2
Published by
The Association of Anaesthetists of Great Britain and Ireland,
21 Portland Place, London W1B 1PY
Telephone: 020 7631 1650, Fax: 020 7631 4352
E-mail: info@aagbi.org Website: www.aagbi.org
February 2005
MEMBERSHIP OF THE WORKING PARTY
EX OFFICIO
February 2005
To be reviewed by 2010
Contents Page
Summary 2
Introduction 3
Recent reports 4
Selection of patients 5
Documentation 9
Management and Staffing 10
Facilities 11
Anaesthetic management 12
Postoperative recovery and discharge 14
Regional anaesthesia 16
Postoperative instructions 17
Discharge summary 18
Audit 19
Contractual arrangements 21
Stand-alone day surgery units 22
References 23
Further reading 24
FAQs 26
Appendix 1 28
Appendix 2 31
Appendix 3 32
Appendix 4 33
Appendix 5 34
Appendix 6 35
1
Summary
Day surgery is a continually evolving specialty performed in a range
of ways across different units.
2
Introduction
The definition of day surgery is not clear and is interpreted differently
by Trusts around the UK; the boundaries between day surgery, 23-h
stay and 2-day stay are often blurred. The principles of care outlined
in this document apply equally to patients managed within all these
formats.
3
Recent Reports
Over the years, many reports have been published to inform those
who wish to extend or improve the manner in which they practise
day surgery. The Audit Commission, Caring for Children in the
Hospital Service and various Department of Health organisations
have all produced papers in this field and these are helpful
background reading (See Further Reading).
The NHS Value for Money report from 1991 Day Surgery: Making it
happen is still well worth reading and everyone should consult the
latest Day Surgery: Operational Guide from the Department of
Health.
NHS Estates have recently updated their building note HBN 26 that
covers facilities for surgical procedures and this, plus the Scottish
Health Planning on accommodation for day care (See Further
Reading), give good advice to those developing new facilities.
4
Selection of Patients
There are various routes for referral to day surgery: from hospital
outpatient clinics, from accident and emergency departments, from
Professionals Allied to Medicine and direct from general practice. The
exact mode of referral is unimportant as long as all adhere to agreed
protocols of patient assessment. There are no absolute criteria of
fitness for day surgery; however, it is important that the criteria are
agreed locally with the Department of Anaesthesia.
Assessment falls into two main categories:
(i) Social
(ii) Medical
Both of these are important. However, some of these factors are not
always easy to assess by the hospital doctor who has to rely on
healthcare professionals in the community to identify potential
problems.
5
(ii) Medical Factors:
(b) The patient should be either fully fit or any chronic disease,
such as diabetes, asthma, hypertension or epilepsy, should be
controlled. (See pre-assessment).
Pre-assessment
In units where policies have been agreed with the local Primary Care
Team, requests for further testing or investigation may be made by
6
GPs (e.g. diabetic or hypertension control or supervised weight loss),
after which the patient can be re-assessed.
7
the patient should be able to mobilise to some extent. It would
appear at first sight that full mobilisation is essential but this is a
relative factor e.g. if the patient is wheelchair-bound and their home
can facilitate such ‘mobilisation’ then day stay should not be
precluded. In the same way, a patient having bilateral foot surgery
may go home in a wheelchair and mobilise over the subsequent
week.
8
Documentation
Not every DSU needs to design its own assessment forms; there are
large numbers of these forms in existence in Great Britain and Ireland,
and throughout the rest of the world. Those about to start, or to update,
their practice should try to obtain as many of these forms as possible to
benefit from the experience of others. A specimen form is shown in
Appendix 1 and further examples are available from the British
Association of Day Surgery, BADS*.
9
Management and Staffing
Each DSU should have a Clinical Lead or Director who has a specific
interest in day case surgery and who will lead the development of
local policies, guidelines and Clinical Governance in this area. A
consultant anaesthetist with management experience is ideally suited
to such a post. This individual should have adequate time allocated
in their job-plan for this responsibility [7]. Each unit also requires
adequate staffing led by a senior nurse who provides the day-to-day
administration of the unit in liaison with the Director. The senior
nurse in charge of the day surgery unit should be expected to spend
the majority of their time within the unit. Hands-on activity by senior
staff members ensures a valid understanding of any problems that can
emerge in day-to-day practice and will enable these to be more
speedily rectified. The staffing levels will depend on the design of the
facility and the work undertaken, as well as local preferences. The
DSU must have reception staff of high quality as well as its own
nursing and ODP personnel. The staff must be specifically allocated
and trained in day surgery.
Each unit should have an operational group which should oversee the
day-to-day running of the unit. This may include representatives from
anaesthesia, surgery, hospital nursing, community nursing, general
practice, pharmacy, management, finance, audit, and ancillary care.
This group should agree an operational policy, define a timetable,
review any operational problems and organise audit strategies.
10
Facilities
Care should be provided in a facility that is set aside for day surgery.
Ideally this should be purpose-built. Alternatively day surgery should
be practised in a dedicated area within the hospital. Simple, rapid
and effective exchange of information between hospital and
community personnel must be possible.
Many hospitals will be providing care for day patients, who require
anaesthesia, in specialised units e.g. ophthalmology, dentistry,
psychiatry, accident and emergency. It may not be appropriate to
centralise these services into one DSU but all such patients must
receive the same high standards of selection, preparation, peri-
operative care, discharge and follow-up.
Children experiencing day surgical care require all the facilities and
staffing that would be expected in any paediatric unit. Those who
practise day surgery for adults and children in the same unit must
ensure that their unit meets the guidelines outlined in Caring for
Children in the Health Services 1991. Just for the Day. National
Association for the Welfare of Children in Hospital, London (see
Further Reading).
11
Anaesthetic Management
Day surgery anaesthesia should be a consultant-led service. However,
as ultimately 75 % or more of all elective surgery may be taking
place in day surgery, consideration should be given to education of
trainees as recommended by the RCA. This will require organised
training schedules and the provision of suitable cover - this is
especially true of stand-alone units.
Once a patient has been selected and fully prepared for day surgery,
decisions must be made for their anaesthetic management. The
Association of Anaesthetists standards on patient monitoring and
assistance for the anaesthetist should be applied [8, 9].
12
Some audits suggest that the routine use of intravenous fluids can
enhance the patients’ feeling of wellbeing.
13
Postoperative Recovery and Discharge
Recovery from anaesthesia can be divided into three phases:
The use of modern drugs and techniques may allow early recovery to
be complete by the time the patient leaves the operating theatre,
allowing a significant number of patients (up to 42% in some studies)
to bypass the first stage recovery area [12]. Adopting this “fast-
tracking” system may theoretically allow cost savings by reducing the
staffing levels in the recovery area, but may increase drug costs. In
addition, for most operating lists, there will need to be some staff in
the recovery area so savings are very difficult to quantify. Whether
this concept is appropriate will depend on local factors such as case
14
mix, and protocols should be established to identify when a patient
may be ‘fast tracked’. It is useful to consider that almost all patients
who undergo surgery with analgesia provided by a local anaesthetic
block will be able to be ‘fast-tracked’.
Work has been done reviewing the evidence for some of the
traditional discharge criteria, in children and adults [13]. It has been
shown that both voiding and/or requiring patients to drink fluids
before leaving the unit are not always necessary, and may delay time
to discharge. It is important to identify and retain patients who are at
particular risk of developing later problems, such as those who have
experienced prolonged instrumentation or manipulation of the
bladder, but protocols could be adapted to allow low risk patients to
be discharged without fulfilling the traditional criteria.
15
Regional anaesthesia
Peripheral nerve blocks can provide excellent conditions for day
surgery. Patients may be discharged home with residual sensory or
motor blockade, providing the limb is protected and assistance is
available for the patient at home. The expected duration of the
blockade must be explained and the patient must receive written
instructions as to their conduct until normal power and sensation
returns. The provision of oral analgesics to be taken as the local
anaesthesia begins to wear off and then subsequently on a regular
basis must not be forgotten.
Central neural blockade can also be used for day stay surgery.
Residual blockade after spinal or caudal anaesthesia may cause
postural hypotension or urinary retention despite return of adequate
motor and sensory function. These problems can be minimised by the
choice of local anaesthetic agent used (e.g. lidocaine) or more
commonly in the UK by the use of low dose local anaesthetic -
opioid mixtures.
Concerns about post dural puncture headache (PDPH) have limited use
of spinals in day stay patients in the past, but the use of smaller gauge
and pencil-point needles has reduced the incidence to less than 1%.
More and more units in the UK are now adopting subarachnoid blocks
as a ‘preferred technique’. Information about PDPH and what to do if
this occurs should be included in the patient’s discharge instructions as
well as the provision of alternative analgesics.
17
Discharge Summary
It is essential to inform the patient’s GP of the nature of the
anaesthetic and surgical procedure performed and of the patient’s
discharge. This may be by letter, facsimile or by email. However,
whichever method is chosen it must be by a secure method of
transmission and approved by the local Caldicott Guardian.
DSUs must agree with their local Primary Care Teams how back-up is
to be provided for patients in the event of problems. Most units
currently run a help-line for the first 24 hours post discharge and
telephone the patient the next day to ensure their well-being.
Telephone follow-up is highly rated by patients and can be a useful
method of auditing any immediate problems. It is important that
discussion does take place with the Primary Care Team as changes in
the provision of ‘out of hours’ Primary Care may lead to the need to
extend hospital-based support.
18
Audit
Effective audit is an essential component of good day stay
anaesthesia. The majority of patients can be discharged home after
day stay surgery but careful recording of admission rates is helpful.
Re-admission to hospital after day stay care is often cited as an
important index of a standard of care but is rarely an accurate
measure as patients may be admitted to other hospitals and thus ‘lost’
to audit.
Discharge of the patient from the DSU to the home is not the only
adequate measure of success for day surgery. Unless it can be
demonstrated that a patient is comfortable at home, with minimum
morbidity, no conclusions can be made.
19
Even detailed co-operation with community healthcare providers may
not allow full ‘capture’ of important data as many patients will seek
help or advice from friends or pharmacists rather than their GP or
hospital.
20
Contractual Arrangements
Day surgical care is no different to any other form of hospital activity
in terms of its contractual arrangements. Theatre and ward work is
similar wherever it is performed and should be recognised as such in
any job plan both for new and old style contracts.
21
Stand Alone Day Surgery Units
It is expected that there were will be an increasing number of stand
alone day surgery units in the UK. Many of these will be Treatment
Centres run by the NHS (TCs) or Independent Sector (ISTCs).
The model of care from an anaesthetic point of view must remain the
same with levels of care, equipment, skilled assistance and recovery
facilities meeting national standards. It is important however, that the
operational policy includes agreement about management of certain
key issues, these include:
Medical cover for the unit until all patients are discharged
22
References
1. The NHS Plan. 2000. Department of Health.
23
12. Lubarsky DA. Fast Track in the Post-anesthesia Care Unit:
unlimited possibilities? Journal of Clinical Anesthesia.
1996;8:70S-72S.
Further Reading
Association of Anaesthetists of Great Britain and Ireland 2001.
Pre-operative Assessment – The role of the Anaesthetist.
Cahill CJ. Basket cases and trolleys – day surgery proposals for the
millennium. The Journal of One-Day Surgery 1999;9(1): 11-12.
24
Caring for children in the Health Services 1991. Just for the Day.
National Association for the Welfare of Children in Hospital, London.
25
FAQ
Should all my patients be able to eat and drink prior to discharge?
Although most patients should be able to eat and drink before
discharge, not all will want to. It has been shown that too aggressive
introduction of oral intake may provoke nausea and vomiting.
Provided patients are warned of the possibility of dehydration and
given advice on what to do if they cannot keep anything down, it is
not necessary that they eat and drink before discharge.
26
How do I introduce new procedures into the day unit?
This depends on many factors – the procedure, the surgeon,
anaesthetic colleagues, nursing staff and even local geography to
name but a few. A simple guide is to evaluate each procedure on an
in-patient or as a 23-hour stay in the first instance. Limit the number
of anaesthetists and surgeons involved at this stage to ensure that you
can optimise (and evaluate) your anaesthetic and analgesic regimens.
This will allow you and your surgical colleague to make step changes
to your management of the patients until you are confident that they
can be discharged safely and with adequate analgesia. Once you
have moved the procedure to the day surgery setting successfully you
can look to expand the number of surgeons and anaesthetists
involved as appropriate. Ensure that all the lessons learned during the
evaluation phase are clearly passed on to colleagues. For more
demanding procedures this will mean setting up guidelines for the
surgeons and anaesthetists.
27
Appendix 1
An example of a preoperative screening assessment for patients who
are being considered for day case surgery as used by the University
Hospital of North Staffordshire.
28
What is your Height? ........................... Blood pressure .............................................
........................... (To be completed by nurse)
What is your Weight? ........................... Heart rate.......................................................
........................... (To be completed by nurse)
Have you ever had a serious illness (if yes please name
......................................................................................
ALLERGY or reaction to medicines, elastoplast, latex,
........................................................
If a woman, are you pregnant or taking the “pill” or HRT?......................................................
(PLEASE NOTE THAT YOU MAY NEED TO BE OFF THE PILL FOR AT LEAST FOUR WEEKS
BEFORE SOME OPERATIONS)
29
Is there anything else the surgeon/anaesthetist should know?
...................................................................................................................................................
Should you have any difficulty in answering any of the above questions please consult your
family Doctor.
Thank you for completing this questionnaire.
TO BE COMPLETED BY SURGEON
REMARKS: PRIORITY: ROUTINE / SOON / URGENT
PROPOSED OPERATION: DAY CASE / INPATIENT
CHECK LIST: CONSENT LA / GA
PREMED TTOS
INVESTIGATIONS COMPLETED
FBC U/E CXR PFT ECG OTHERS
30
Appendix 2
Example patient information sheet
31
Appendix 3
Management of the patient with postoperative nausea/vomiting.
Policy from Day Surgery and Treatment Unit, York Hospitals NHS
Trust
32
Appendix 4
Oral Analgesia Prescription for Adult Patients
Day Surgery and Treatment Unit
Please prescribe oral analgesia for patients on this form. 4 choices are
provided for analgesia depending on expected severity of discomfort
following the operation. Non standard analgesia regimes may still be
prescribed on the patients discharge letter on the few occasions this should
be necessary. Each patient will receive 1 standard day unit pack of the
drugs prescribed.
Minor
Drug Dosage Signature
Co-codamol 8/500 2 tablets 4 - 6 hourly
Intermediate
Drug Dosage Signature
Diclofenac (Voltarol) 50mgs 8 hourly
Major
Drug Dosage Signature
Diclofenac (Voltarol) 50 mgs 8 hourly
Intermediate or Major
Drug Dosage Signature
Co-codamol 30/500 1 - 2 capsules 4 - 6 hourly
Policy from Day Surgery and Treatment Unit, York Hospitals NHS Trust
33
Appendix 5
Modified Aldrete Score
Activity – can move voluntarily on command
4 extremities 2
2 extremities 1
0 extremities 0
Respiration
Able to deep breathe and cough freely 2
Dyspnoea, shallow, or limited breathing 1
Apnoea 0
Consciousness
Fully awake 2
Rousable to speech 1
Not responding 0
O2 saturation
Maintains O2 saturation >92% on room air 2
Needs O2 supplement to maintain SpO2 > 90% 1
O2 saturation <90% even with O2 supplement 0
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Appendix 6.
An example of discharge criteria following day case surgery as used by
Kings Lynn and Wisbech Hospitals.
Comments: Transport
Help line number given
out of hours & unit number
Seen by physio
Block/spinal leaflets given
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Notes
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21 Portland Place, London W1B 1PY
Tel: 020 7631 1650
Fax: 020 7631 4352
Email: info@aagbi.org
www.aagbi.org